Provider Demographics
NPI:1609180413
Name:FUNDERBURK, MILLIE RISS (PSYD, LPC)
Entity Type:Individual
Prefix:DR
First Name:MILLIE
Middle Name:RISS
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:DR
Other - First Name:MILLIE
Other - Middle Name:MARGARET
Other - Last Name:RISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LPC
Mailing Address - Street 1:1705 S PEARL ST
Mailing Address - Street 2:UNIT 4
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3170
Mailing Address - Country:US
Mailing Address - Phone:303-818-1284
Mailing Address - Fax:
Practice Address - Street 1:1705 S PEARL ST
Practice Address - Street 2:UNIT 4
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-3170
Practice Address - Country:US
Practice Address - Phone:303-818-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical